Five children, ranging in age from 10 months to 4 years, all presenting initially with headache, with or without vomiting, and in whom the final diagnosis was intracranial tumor, are reported from Petah Tiqva, Israel. The initial neurologic examination, including the fundi, was normal in three patients with craniopharyngioma, pinealoma, and cerebellar astrocytoma. Two patients with medulloblastoma and fourth ventricle choroid plexus papilloma had abnormal neurologic findings at presentation. The authors stress the need for neuroimaging studies in children younger than 4 years of age who have headache, especially if accompanied by vomiting, even if the neurologic exam is normal. 
COMMENT. In response, Shinnar S and Chu ML emphasize that a presenting complaint of headache, even in young children, is generally associated with a benign clinical syndrome, and a neuroimaging study is not always necessary or advisable. The heavy sedation required for the MRI in this age group and risks of an adverse reaction to contrast medium with CT must be weighed against the benefits of the study. They agree with Honig PJ and Charney E  that headache as the sole manifestation of brain tumor is very uncommon in young children.
Headache in young children is not only a problem in evaluation but also in recognition as a significant isolated symptom. Clinical acumen and careful judgement are required in decisions, 1) to advise a neurologic consultation, and 2) to order sophisticated or invasive tests. The pediatric neurologist usually has the benefit of a pediatrician’s knowledge of the child and family and his decision to seek a second opinion. Notwithstanding the relatively rare occurrence of cerebral tumor in children who present with headache, uncomplicated by some other manifestation, the pediatric neurologist’s first duty is to exclude the more serious diagnoses. The value of the electroencephalogram as an important preliminary test in the diagnosis and localization of intracranial tumors of children should not be forgotten.